Psychiatry: Far From the Madding Grief?

The Diagnostic Statistical Manual of Mental Disorders is the official classification manual developed for use in clinical, educational, and research settings; it is published by the American Psychiatric Association (APA) and is regularly revised. The fifth edition (DSM-5) is expected to appear in May 2013. In the DSM’s current edition (DSM-IV), feelings of sadness and associated symptoms (e.g., insomnia, poor appetite, and weight loss), following the death of a loved one are excluded from the criteria for a Major Depressive Disorder (MDD), but a cautionary clause states that if these symptoms continue beyond two months and impair the individual’s psychological, social and occupational functioning, she may be given an MDD diagnosis.

The DSM-5 Working Group for the Mood Disorders has recently proposed the removal of the bereavement exclusion from the diagnostic criteria for a Major Depressive Disorder (MDD), arguing that the available evidence does not support distinguishing bereavement from other stressors that underlie MDD.

This proposal has led to a controversial debate on the advantages and disadvantages of distinguishing between the cases that involve individuals who develop major depression in response to bereavement and those who develop depression following other severe stressors. For instance, Allen Frances, the lead editor of DSM-IV, is concerned that removing the bereavement exclusion will result in over-diagnosing and over-treating non-pathological grief by labelling it MDD.

The proposed change also raises concerns about lowering the diagnostic thresholds for disorder categories, including MDD, as this may lead to inappropriate medical treatment of vulnerable populations. Some maintain that this adjustment will better address a grieving individual’s needs, however, as she will be able to receive some therapeutic help while coping with loss; in addition, her expenses will be covered by insurance companies, as her concerns will be a legitimate health condition.

Grief is a complex process, through which the individual mourns the loss of a loved one, negotiates the demands of the new world without the loved one in it, and adjusts her new way of being-in-the-world without that person.

What worries me about diagnosing the multifaceted and complex grief experience as depression is its influence on the patient’s conceptualization and understanding of her grief and her concomitant response. If she takes her grief experience as a form of illness, without due appreciation of its true complexity two things may occur. First, she may become less inclined to discover the qualitative and subjective features of grief experience, to situate it in her interpersonal relationships, and to negotiate her own response, relying instead on the psychiatric language of depression which lacks depth because it is merely an operational framework designed to facilitate diagnosis and treatment across different settings. Second, the psychiatric language, which lacks the subjective context of the grief encounter by virtue of focusing on the patient’s observable symptoms not her life as a whole, may direct the patient’s attention away from her personal experience of grief towards an impersonal illness. (I addressed similar concerns on the epistemic influence of psychiatric diagnoses, in particular, on the influence of mood disorder diagnosis on self-insight, here, and the DSM diagnoses at large on self-concepts, here.)

Does it matter if the grieving person engages with her subjective experience of grief using her own language, rather than the psychiatric language of depression? Some empirical evidence suggests that it does. For example, James Pennebaker’s empirical work on the value of writing about traumatic experiences on the subject’s well-being demonstrates that when individuals write about traumatic experiences by deeply engaging with the associated emotional difficulties in their lives, significant physical and mental health follows. This is called the disclosure phenomenon. Pennebaker’s studies indicate that writing about deep feelings related to a traumatic experience is associated with a significant drop in physician visits and has a beneficial influence on immunity. While some positive outcomes of the disclosure phenomenon can be attributed to a reduction in inhibition, Pennebaker and his colleagues argue that basic cognitive and linguistic processes involved in writing are a more significant factor in these positive outcomes. Support comes from the observed connection between language and health outcomes: thoughtful and deep writing, which draws causal and insightful connections between the events and emotions, as well as the use of positive emotion words in expressing trauma, leads to better health outcomes. In the case of grief, therefore, perhaps the individual will better cope with the loss of a loved one, if she is encouraged to explore her feelings connected to his presence in her life, the sadness that comes with his loss, and so on.

Whether the alteration of the diagnostic criteria for the MDD by removing the bereavement exclusion criteria and diagnosing grief-associated emotional difficulties as depression will lead to the problems I suggest here is largely empirical. It depends on the person, the psychiatric context in which she receives diagnosis, and the particular therapist who diagnoses her. But we must pay attention to the moral psychology and reasoning of the persons most influenced by these changes. At the next meeting of the American Psychiatric Association in Philadelphia in May 2012, the representatives of the DSM-V task force will answer questions pertaining to these changes. I look forward to hearing whether they have fully considered the complex ramifications of change.

2 Responses

Leaving all my reservations about the DSM aside, I think the main issue here is whether the psychiatrists should diagnose individuals differently if they recently experienced the loss of a loved one, even if they meet all other criteria of MDD. If they continue to exclude bereavement, there are various disadvantages to the person in question as you mentioned, e.g., the insurance companies does not cover the expenses. On the other hand, if they remove the bereavement exclusion, there is the potential of over-diagnosis. For instance, psychiatrists in most of the public hospitals in Turkey have to see patients and diagnose them in a very short time. I have not found any statistic information on how many minutes a psychiatrist spends per patient in Turkey but the reports of my students whom I had to refer to a psychiatrist corroborate this. According to the Psychiatric Association of Turkey, as of 2011 the patient/psychiatrist ratio is 2,2/100000. Hence, especially in countries like Turkey, where psychiatrist do not have the time to go into depth with patients’ problems most of the time, probably the criteria work as a quick checklist to diagnose. So, if bereavement is excluded, there is a potential to miss someone who suffers from MDD due to her recent loss of a loved one, and if bereavement is excluded, there is a potential of over-diagnosis which has its own disadvantages medically and economically. I believe this would be a more manageable problem if psychiatrists had more time for each patient and could decide case by case (this still would require the removal of the exclusion), but as I have mentioned this is not the case. Apparently, more research on the relationship between bereavement and depression needs to be conducted.

By the way, I wonder which position the drug companies support which I believe is a big deal as it is a considerable influence in the decision. I would not be surprised if they do not mind over-diagnosis much.

I share your concerns pertaining the length of the time the psychiatrist actually spends with patient. Thanks for the Turkey statistics, it sounds disturbing. The situation is not any better in North America, if not actually worse. First of all, both in Canada and US, patients first have to see family physicians for diagnosis and treatment. Family physicians –who have very minimal training in psychiatry– thus are able to diagnose individuals with mental disorders and offer appropriate treatment. Only when/if the individual is at a high risk of hurting himself, or his symptoms are not alleviated through the initial treatment offered, he is referred to a psychiatrist. Family physicians are allowed to spend only 15 minutes with each patient. So, as you say,they go through a check-list of symptoms to diagnose the patient; raising the risk of false or inappropriate diagnosis, among other things.
Drug company representatives have been part of the DSM decision making process, in various capacities, since the publication of the DSM-III; and clearly they have vested interests in any opportunity that would increase the drug treatment. I have not read of a specific work on where drug companies stand in the bereavement exclusion case, but I agree with your intuition on where they might stand. I will keep you posted if I find anything.